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Writing Patient Client Notes Ensuring Accuracy in Documentation 4th Edition by Ginge Kettenbach ISBN 0803618786 9780803618787

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Writing Patient Client Notes Ensuring Accuracy in Documentation Fourth Edition Ginge Kettenbach Digital Instant Download

Author(s): Ginge Kettenbach
ISBN(s): 9780803618787, 0803618786
Edition: 4
File Details: PDF, 6.28 MB
Year: 2009
Language: english
SKU: EB-1860354 Category: Tag:

Writing Patient Client Notes Ensuring Accuracy in Documentation 4th Edition by Ginge Kettenbach – Ebook PDF Instant Download/Delivery: 0803618786, 9780803618787
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Product details:

ISBN 10: 0803618786 
ISBN 13: 9780803618787
Author: Ginge Kettenbach

An ideal resource for any health care professional needing to learn or improve their skills―with simple, straightforward explanations of the hows and whys of documentation. It also keeps pace with the changes in Physical Therapy practice today, emphasizing the Patient/Client Management model. Section by section, exercise by exercise, the 4th Edition will help you to to write clear, concise, and correct patient care notes using a variety of tools, including SOAP notes.

Writing Patient Client Notes Ensuring Accuracy in Documentation 4th Table of contents:

I. Background Information

  1. Introduction to Note Writing

  2. Writing in a Medical Record

  3. Medical Terminology / Worksheets

  4. Using Abbreviations / Worksheets

II. Documenting the Examination
5. The Patient/Client Management Format: Writing History / Worksheets
6. The Patient/Client Management Format: Writing Systems Review / Worksheets
7. The Patient/Client Management Format: Documenting Tests and Measures / Worksheets

  • Review Worksheet: Writing the History, Systems Review, and Tests & Measures

  1. The SOAP Note: Stating the Problem

  2. The SOAP Note: Writing Subjective (S) / Worksheets

  3. The SOAP Note: Writing Objective (O) / Worksheets

  • Review Worksheet: Stating the Problem, S & O

III. Documenting the Evaluation (A)
11. Writing Evaluation
12. Writing the Diagnosis
13. Writing the Prognosis / Worksheets

  • Review Worksheet: History, Systems Review, Tests & Measures, Evaluation, Diagnosis, Prognosis

  • Review Worksheet: Problem, S, O, A

IV. Documenting the Plan of Care (P)
14. Writing Expected Outcomes (Long-Term Goals) / Worksheets
15. Writing Anticipated Goals (Short-Term Goals) / Worksheets
16. Documenting Planned Interventions / Worksheets

  • Final Review Worksheet: Patient/Client Management Note: History, Systems Review, Tests & Measures, Evaluation, Diagnosis, Prognosis, Plan of Care

  • Final Review Worksheet: Problem, S, O, A, P

V. The Medical Record
17. Overview of the Medical Record
18. Legal Issues
19. Reimbursement

VI. Applications of Documentation Skills
20. Applications and Variations in Note Writing
21. Alternatives: Documentation Forms and Computerized Documentation
22. The Future: Documentation Using the ICF System

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Tags: Ginge Kettenbach, Writing Patient, Client Notes